P R Jirge1, S M Chougule1, A Keni2, S Kumar3, D Modi4. 1. Deparment of Reproductive Medicine, Sushrut Assisted Conception Clinic, Shreyas Hospital, 6th Lane, Rajarampuri, Kolhapur, India. 2. Deparment of Critical Care, & Pulmonology, Aster Aadhar Hospital, 628, B Ward, Shastri Nagar, Kolhapur, India. 3. Department of Pulmonology and Sleep Medicine, Excelcare Hospital, 27th Cross, Banashankari II Stage, Bangalore, India. 4. Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR), JM Street, Parel, Mumbai, India.
Abstract
STUDY QUESTION: What is the effect of latent genital tuberculosis (GTB) on ovarian reserve in infertile women? SUMMARY ANSWER: Women with latent GTB have lower ovarian reserves and yield lower numbers of oocytes in IVF. WHAT IS KNOWN ALREADY: Limited evidence suggests that women with GTB may have a low ovarian reserve. Infertile women have a high incidence of latent GTB and treatment improves fertility outcomes. STUDY DESIGN, SIZE, DURATION: This prospective study from February 2013 to January 2016 compared 431 infertile women diagnosed with latent GTB (Group I) to 453 infertile women without latent GTB (Group II). PARTICIPANTS/MATERIALS, SETTING, METHODS: The study was conducted at Shreyas Hospital, Kolhapur, India, a tertiary referral centre for infertility. Women of both groups were 21-38 years of age. Group I consisted of infertile women with proven tubal patency but with latent GTB diagnosed by DNA PCR testing of an endometrial biopsy. Day 2-4 anti-Mullerian hormone (AMH) and antral follicle count (AFC) were assessed in both groups. All women with latent GTB took antituberculosis therapy (ATT). Gonadotropin dosages and oocyte and embryo details were noted in both groups for those who underwent IVF. MAIN RESULTS AND THE ROLE OF CHANCE: Women with latent GTB were younger (29.8 ± 4.4 years vs. 30.8 ± 4.5 years; P = 0.003) and, following adjustment for age, had significantly lower AMH [Median (IQR): 2 (0.9, 4.1) ng/ml vs 2.8 (1.3, 5) ng/ml; P = 0.01] and AFC [Median (IQR): 7 (5, 11) vs 8 (5, 14); P < 0.001]. Post ATT, women with latent GTB yielded fewer oocytes (9.3 ± 7.6 vs. 10.9 ± 8.1; P = 0.01), but had more grade I embryos transferred (1.1 ± 0.5 vs. 0.89 ± 1.0; P = 0.001) and a better implantation rate (26.8% vs. 17.5%; P = 0.004) in IVF compared to women in Group II. Group I had a higher pregnancy rate compared to Group II (51.6% vs. 40.5%; P = 0.001), through various treatment modalities. Considering the adequacy of the sample size and use of robust ovarian reserve markers, the role of chance is minimal. LIMITATIONS REASONS FOR CAUTION: The study is limited to an infertile population visiting a tertiary referral centre. The mechanisms by which latent GTB infection would lead to ovarian damage are unclear. WIDER IMPLICATIONS OF THE FINDINGS: It is believed that latent GTB is without any clinical significance. However, a low ovarian reserve in young women with latent GTB necessitates considering it as a cause of infertility, in women with prolonged infertility. These women may experience an accelerated decline in ovarian reserve with reduced success in achieving biological parenthood. Clinicians must be aware of this condition and its consequences while managing infertility. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by Sushrut Assisted Conception Clinic, Shreyas Hospital, Kolhapur, India. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.
STUDY QUESTION: What is the effect of latent genital tuberculosis (GTB) on ovarian reserve in infertile women? SUMMARY ANSWER: Women with latent GTB have lower ovarian reserves and yield lower numbers of oocytes in IVF. WHAT IS KNOWN ALREADY: Limited evidence suggests that women with GTB may have a low ovarian reserve. Infertile women have a high incidence of latent GTB and treatment improves fertility outcomes. STUDY DESIGN, SIZE, DURATION: This prospective study from February 2013 to January 2016 compared 431 infertile women diagnosed with latent GTB (Group I) to 453 infertile women without latent GTB (Group II). PARTICIPANTS/MATERIALS, SETTING, METHODS: The study was conducted at Shreyas Hospital, Kolhapur, India, a tertiary referral centre for infertility. Women of both groups were 21-38 years of age. Group I consisted of infertile women with proven tubal patency but with latent GTB diagnosed by DNA PCR testing of an endometrial biopsy. Day 2-4 anti-Mullerian hormone (AMH) and antral follicle count (AFC) were assessed in both groups. All women with latent GTB took antituberculosis therapy (ATT). Gonadotropin dosages and oocyte and embryo details were noted in both groups for those who underwent IVF. MAIN RESULTS AND THE ROLE OF CHANCE: Women with latent GTB were younger (29.8 ± 4.4 years vs. 30.8 ± 4.5 years; P = 0.003) and, following adjustment for age, had significantly lower AMH [Median (IQR): 2 (0.9, 4.1) ng/ml vs 2.8 (1.3, 5) ng/ml; P = 0.01] and AFC [Median (IQR): 7 (5, 11) vs 8 (5, 14); P < 0.001]. Post ATT, women with latent GTB yielded fewer oocytes (9.3 ± 7.6 vs. 10.9 ± 8.1; P = 0.01), but had more grade I embryos transferred (1.1 ± 0.5 vs. 0.89 ± 1.0; P = 0.001) and a better implantation rate (26.8% vs. 17.5%; P = 0.004) in IVF compared to women in Group II. Group I had a higher pregnancy rate compared to Group II (51.6% vs. 40.5%; P = 0.001), through various treatment modalities. Considering the adequacy of the sample size and use of robust ovarian reserve markers, the role of chance is minimal. LIMITATIONS REASONS FOR CAUTION: The study is limited to an infertile population visiting a tertiary referral centre. The mechanisms by which latent GTB infection would lead to ovarian damage are unclear. WIDER IMPLICATIONS OF THE FINDINGS: It is believed that latent GTB is without any clinical significance. However, a low ovarian reserve in young women with latent GTB necessitates considering it as a cause of infertility, in women with prolonged infertility. These women may experience an accelerated decline in ovarian reserve with reduced success in achieving biological parenthood. Clinicians must be aware of this condition and its consequences while managing infertility. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by Sushrut Assisted Conception Clinic, Shreyas Hospital, Kolhapur, India. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.